APPLICATION FORM FOR USE AT CLUB AND DISTRICT INTERVIEWS
This application MUST BE TYPEDin the areas required.
Dear Rotary District 9800,
I am interested in participating in the Rotary Youth Exchange Program. My personal details are as follows:
Surname:Click here to enter text. Given Names:Click here to enter text.
Father’s Name:Click here to enter text. Mother’s Name:Click here to enter text.
Address:Click here to enter text.
Post Code:Click here to enter text.Home Phone:Click here to enter text.Mobile: Click here to enter text.
Date of Birth:Click here to enter text. Email:Click here to enter text.
Religion: Click here to enter text.Gender: Click here to enter text.
Note: To be eligible, you must not be older than 17 years and 6 months of age as at 1st January 2020 and not have completed year 12 studies. You are also expected to return to school after your exchange.
School: Click here to enter text.Year Level: Click here to enter text.
Subjects being studied: Click here to enter text.
My extra-curricular interests and activities at school are: Click here to enter text.
My other interests and hobbies are: Click here to enter text.
Books that I have read (other than school texts) in the past 3 months: Click here to enter text.
My part-time employment experience has been: Click here to enter text.
My previous extended travel or periods away from home been: Click here to enter text.
My roles of leadership in or out of school are: Click here to enter text.
My previous experience speaking before school, church or social group is: Click here to enter text.
I have studied the following foreign language(s): Click here to enter text.forClick here to enter text.year(s).
I am aware of and concerned about the following major issues confronting the future of Australia:
Click here to enter text.
District 9800 conducts exchanges with a number of different countries, these include the following:
Sweden, France, Denmark, Poland, Germany, Finland, Hungary, Taiwan, Norway, Brazil, Austria,Switzerland and Spain.
We cannot guarantee any student their preference as it depends on a country’s willingness to take students from our District and the number of places available. You may however indicate the countries or regions you would be interested in.
Chosen country and brief reasons for choice: Click here to enter text.
I wish to be an Exchange Student for 12 months for the following reasons:Click here to enter text.
The following have agreed to act as my referees:
1) At school e.g. House Master, Coordinator etc.
2) Outside school e.g. My Part-time Employer, Community Leader etc.
Give full name, address, work/home telephone numbers for the above:
1)Click here to enter text.
2)Click here to enter text.
Student’s Signature:Click here to enter text.Parent’s Signature: Click here to enter text.
Date: Click here to enter text.Date: Click here to enter text.
Rotary Club use only
Sponsoring Rotary Club …………………………………………………………
Endorsed by ………………………………………………………………………
If you have any queries in filling out the form please email your queries to Peter Lamping at or call 0418 510 312
Upon completion and acceptance by sponsoring Rotary Club (if known), and prior to closing date for applications of 8thApril 2019 please emailsaved document or scan and email to:
District 9800 Youth Exchange Secretary
Peter Lamping at